Lane County has an unacceptably high rate of fetal-infant mortality. The overall rate is higher than the state rate and higher than comparable counties and metropolitan areas. Until recently, it was also higher than the national average. See a rate comparison graph here. Improving on the national rate is a positive development but it should be noted that 29 nations have lower infant mortality.
A community’s rate of fetal and infant mortality reflects its health and socio-economic wellbeing. It indicates the capacity and effectiveness with which government, health and social welfare services deploy resources. Accordingly, Lane County’s fetal-infant mortality rate sends a strong distress signal. Simple explanations or straightforward solutions are elusive. Rates vary within and across population groups due to numerous variables including geography, education, ethnicity, age, socioeconomic status as well as physical and mental health. Access to health care and social services are also important factors. Against this backdrop, our local responses are constrained by the current economic climate and shaped by state and federal healthcare legislation.
In 2007, Lane County Public Health (LCPH) staff observed a high rate of infant mortality. Using the Perinatal Periods of Risk (PPOR) methodology to analyze local fetal-infant birth and death data, LCPH confirmed initial suspicions. PPOR is an evidence-based and internationally respected data analysis tool that looks at fetal and infant deaths in relation to birth weight and age at death.
PPOR established Lane County’s rate of fetal-infant mortality as widespread and statistically significant in all population groups regardless of economic, educational, geographic, age, and cultural status. The highest rate of excess fetal-infant deaths occurs in the post-neonatal period from one month to one year of age. Ill-defined causes (includes SIDS) and external causes (includes accidents) are often cited in these deaths. Many successful prevention models exist to reduce these mortalities.
The community responded to the PPOR results with the Healthy Babies, Healthy Communities Initiative (HBHC), a coalition of community partners committed to reducing local fetal-infant loss. HBHC members have identified and employed the Fetal Infant Mortality Review (FIMR) as its best instrument for effective problem solving. Developed by the Maternal Child Health Bureau and the American College of Obstetricians and Gynecologists, FIMR is a well-regarded, evidence-based approach used successfully by other communities. See an explanation of the FIMR process here.
When a fetal or infant death occurs, the FIMR case review team collects information from medical records and conducts a voluntary maternal home interview. De-indentified information is compiled and reviewed to identify critical community strengths and weaknesses, as well as unique health and social issues associated with the losses. Recommendations for new policies, practices, and/or programs are developed and shared with the broader community known as the community action team. The first FIMR report was issued in 2007.
The latest Lane Co. Fetal-Infant Mortality Data
In June, HBHC received the 2010 FIMR report for the period of July 1, 2007 to June 30, 2009. During this period, Lane County families suffered 62 fetal and infant mortalities. Twenty-five percent of mothers consented to an interview with the case review team. Hopefully, in the future more women and families will share their stories. Increasing their participation will provide a more powerful understanding of their experiences and means to identify and bridge gaps in support.
The 2010 FIMR report describes levels of first-trimester prenatal care, payment for care and poverty and homelessness for this group.
Inadequate prenatal care is linked to increased risk for low birth weight, prematurity and infant and maternal mortality. Barely 66% of the 62 Lane County women in this group received prenatal care in the first trimester.
||Lane 2007 Births
||OR PRAMS 2007 Births
||US 2004 Births
|First Trimester Care
Payment for care
Health insurance coverage determines access to prenatal care for most women. Oregon Health Plan (Medicaid) offers coverage for pregnant women. In 2008, OHP began requiring a certified birth certificate for application. This is a major barrier to women accessing prenatal care.
Poverty and Homelessness
- 54.8% of the FIMR cohort were at or below the Federal Poverty Level
- 21% had no stable housing during pregnancy or at birth
Increasing access to prenatal care and reducing poverty and homelessness would, no doubt, have the greatest impact on reducing local losses. While community partners can speak to the importance of these issues, predicating improved outcomes on removing them would quickly lead to inaction. Legislation to improve maternal and infant outcomes and an economic recovery fall well beyond HBHC’s reach. FIMR provides the tools by which communities can move beyond seemingly impossible obstacles to identify goals and resources that are within reach. Based on the most recent FIMR case review process, five specific areas are recommended for community action. Of the following five, HBHC selected two issues for immediate focus – they are obesity/overweight and smoking.
1. Maternity overweight and obesity
Both overweight and obesity pose risks for women and babies. Overweight and obese women are at greater risk for infertility, hypertension, gestational diabetes, preeclampsia and large-for-gestational-age babies. Babies are at greater risk for birth defects and fetal and neonatal death.
||Lane FIMR (58 of 62)*
||Oregon PRAMS 2007**
|Overweight & Obesity
|Overweight (BMI 25-29.9)
|Obesity (BMO > or = 30)
* BMI and/or height and weight was not recorded in 4 of 62 records
** PRAMS refers to Pregnancy Risk Assessment Monitoring System
2. Tobacco consumption
If all pregnant women stopped smoking there would be an 11% reduction in fetal deaths and a 5% reduction in infant deaths. (March of Dimes)
||OR PRAMS 2007
||US PRAMS 2005
|During 3 mos. before pregnancy
|During 3 mos. after pregnancy
3. Maternal mental health
Because screening and referral for mental health is inconsistent the true prevalence of depression during and after pregnancy is unknown. Depression during and/or after pregnancy can make it difficult for a woman to care for herself and to bond with her unborn/born child.
|Lane FIMR Cohort
|2007 OR PRAMS Cohort
4. Reproductive health planning
Women for whom pregnancies are not planned are less likely to discover their pregnancies early, and less likely to adopt healthy behaviors, and begin prenatal care.
||Lane FIMR (43 of 62)
||OR PRAMS 2007
5. Sudden Infant Death Syndrome (SIDS)
SIDS is the leading cause of post-neonatal death in the US. The Lane FIMR review process identified one neonatal and five post neonatal instances of potentially unsafe sleep practices based on medical examiner findings.
Moving toward community action….. While sufficient county funds are unlikely to materialize in the current economic climate, it is imperative that we maintain the groundwork laid by Lane County Public Health and HBHC. Specifically, maintaining funding and staff time for PPOR and FIMR are a necessity for tracking and responding to the unacceptable rate of fetal-infant mortality in our community.
PPOR and FIMR are the backbone for HBHC coalition building and action. Meetings are well attended by local and state government agencies and county-based non-profits. Additional participation from the business community, citizenry and media outlets would further strengthen current efforts. The following are three HBHC-inspired action items, three ways in which we can start working on solutions:
Screening & Referral
Lane County providers lack effective tools to screen for, address and reduce health, psychosocial, and other risk factors to improve maternal and infant outcomes. The current screening tool is paper-based and outdated. The UO FEAT and Health Policy Research Northwest, HBHC coalition members, are working to address this gap in care. The goal is electronic screening and referral kiosks in provider offices.
Home visits improve mother and infant outcomes. HBHC’s Home Visiting Project is identifying and coordinating across local home-visiting programs to collaborate on and support consistent messaging and outreach in line with community action items.
A local breastfeeding coalition recently formed to support increased access to evidence-based breastfeeding services. With regard to SIDS, a 2009 study in the journal Pediatrics shows that breastfeeding reduced the risk of SIDS by 50% at all ages throughout infancy.